duke case review. patient’s history hpi: 52 year old woman presents with two weeks of diplopia and...

Duke Case Review

Patient’s History

• HPI: 52 year old woman presents with two weeks of diplopia and headache.

• Physical exam: Left partial sixth nerve palsy. Reports diplopia on bilateral lateral gaze.

What is true about this vascular anomaly?

• 1) There is a single, large basilar aneurysm

• 2) The aneurysm has a narrow neck

• 3) The basilar artery is fenestrated

• 4) There is no thrombus within the aneurysm.

What is true?

• 1) The 5 year rupture rate of a 5 mm aneurysm is 5 %

• 2) The 5 year rupture rate of a 25 mm basilar aneurysm is 50%

• 3) Narrow neck aneurysms are more difficult to treat

• 4) Basilar aneurysms are easier to clip

• 5) MCA aneurysms are easier to coil than clip.

Corrected answers

• 1) The 5 year rupture rate of a 5 mm aneurysm is .01 %

• 2) The 5 year rupture rate of a 25 mm basilar aneurysm is 50%

• 3) Narrow neck aneurysms are easier to treat• 4) Basilar aneurysms are easier to coil• 5) MCA aneurysms are easier to clip

Findings

• Giant, broad-necked basilar aneurysm measuring 26 mm in greatest dimension.

• How do you treat this aneurysm?

• Does the fenestration affect your treatment plan?

• What are you going to do about the smaller 3 mm aneurysm?

How to use the neuroform stent

How to use the neuroform stent

How to use the neuroform stent

How to use the neuroform stent

Which of the following risks of the procedure is the most likely to

occur?

• 1) Aneurysm swelling post-coiling requiring steroids to prevent symptoms.

• 2) Embolic stroke.• 3) Coil compaction requiring repeat

procedure.• 4) Aneurysm rupture due to manipulation

of the aneurysm.

Which of the following risks of the procedure is the most likely to

occur?

• 1) Aneurysm swelling post-coiling requiring steroids to prevent symptoms.

• 2) Embolic stroke.• 3) Coil compaction requiring repeat

procedure.• 4) Aneurysm rupture due to manipulation

of the aneurysm.

Which of the following risks of the procedure is the most likely to

occur?

• 1) Aneurysm swelling post-coiling requiring steroids to prevent symptoms.

• 2) Embolic stroke.• 3) Coil compaction requiring repeat

procedure.• 4) Aneurysm rupture due to manipulation

of the aneurysm.

Conclusion

• 1) Rupture rate for aneurysms < 7mm is low (.01% per year) and, if they are asymptomatic, most would recommend serial imaging rather than therapy.

• 2) The location, size and neck of the aneurysm are all important factors when planning therapy.

• 3) Coiling is generally favored over clipping of aneurysms.

• 4) Use the neuroform stent for broad necked aneurysms.